MIDLANDS TECHNICAL COLLEGEASSOCIATE DEGREE NURSING

NURSING 165 DATA COLLECTION TOOL

DATE: ___09/28/10_______________ STUDENT: ______Marilyn Stalnaker__________

PATIENT’S GENDER____F_____AGE: __71____ADMISSION DATE: _____09/19/10____________

CLINICAL AREA: __7 west Richland_______

Admitting Diagnosis___Acute Renal Failure____________________________________________________________________________________________________________________________________

1. Medical Diagnosis/Pathophysiology. Include signs and symptoms. Give reference source.

Acute Renal Failure: A rapid decrease in kidney function, leading to the collection of metabolic wastes in the body. ARF can result from conditions that reduce blood flow to the kidneys (pre renal failure), damage to the glomeruli, interstitial tissue, or tubules (intrarenal/intrinsic renal failure); or obstruction of urine flow (post renal failure). When ARF occurs in patients who already have renal insufficiency, it may lead to end stage kidney disease or it may resolve to the previous level of renal function. Many factors contribute to renal insults in acute renal failure, but the acute syndrome may be reversible with prompt intervention.

The pathologic process of acute renal failure is related to the cause of the sudden decrease in kidney function and to the affected kidney sites. Reduced blood flow, toxins, tubular ischemia, infections, and obstruction have different effects on the renal system. Any of these can reduce glomerular filtration rate, damage nephron cells, and obstruct urine flow in the renal tublules.

Symptoms include: Swelling, especially of the legs and feet, little or no urine output, thirst and a dry mouth, rapid heart rate, feeling dizzy when you stand up. Loss of appetite, nausea, and vomiting, feeling confused, anxious and restless, or sleepy, pain on one side of the back, just below the rib cage and above the waist (flank pain).

Ignatavicius,Workman (2006). Medical-Surgical Nursing: Patient Centered Collaborative Care. St. Louis, Missouri: Saunders.

2. Medical Diagnosis/Pathophysiology. Include signs and symptoms. Give reference source.

 Ischemic colitis encompasses a number of clinical entities, all with an end result of insufficient blood supply to a segment or the entire colon. This disease results in ischemic necrosis of varying severities that can range from superficial mucosal involvement to full-thickness transmural necrosis. Bowel ischemia is mainly a disease of old age caused by atheroma of mesenteric vessels. Other causes include embolic disease, vasculitis, fibromuscular hyperplasia, aortic aneurysm, blunt abdominal trauma, disseminated intravascular coagulation, irradiation,

and hypovolemic or endotoxic shock. Occlusive mesenteric infarction (embolus or thrombosis) has a 90% mortality rate, whereas nonocclusive disease has a 10% mortality rate.Venous infarction occurs in young patients, usually after abdominal surgery. Patients may present with colicky abdominal pain, which becomes continuous. It may be associated with vomiting, diarrhea, or rectal bleeding..

Symptoms include: abdominal pain, tenderness or cramping, localized to the lower left side of the abdomen; the onset can be sudden or gradual, bright red or maroon-colored blood in stool or, at times, passage of blood alone without stool, a feeling of urgency to move bowels, diarrhea, nausea, vomiting. The risk of severe complications from ischemic colitis increases when signs and symptoms affect the right side of the abdomen. The arteries that feed the right side of the colon also feed part of the small intestine. When blood flow is blocked on the right side of the colon, it's likely that part of the small intestine also is not receiving adequate blood supply and pain will be more severe. Blocked blood flow to the small intestine may quickly lead to death of intestinal tissue (infarction or necrosis). If this occurs, surgery to clear the blockage and to remove the portion of the intestine that has been destroyed is necessary.

Ali Nawaz Khan, MBBS, FRCS, FRCP, FRCR. (Sep 1, 2009). Colitis, Ischemic. In eMedicine Specialties. Retrieved September 30, 2010, from http://emedicine.medscape.com/article/366808-overview.

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Midlands Technical CollegeClinical Organizational Worksheet

Daily Plan Treatments0700preconference

Weight ______ Height ______ BMI ___VS Freq. standard___

Vital Signs: Pt. norms _99.2T_91_P _24__R _142/92 P _98_poxDay 1:Time_1200_T _98.2_P _86__R 148/88__BP __98__pox

Time_0900_T _99.2_P _82__R _146/74_BP __98__pox

Time_0800_T _98.4_P _91__R _98/141_BP __98__pox

Time_0342_T _99.2_P _82__R _146/74_BP __98__pox

Day 2: Time 2343T _98.4 P 97___R _20___BP _142/92pox

Time_2100T 98.1 P _102_R 20____BP _94/111pox

Time_16:35 T100.1 P _70_R 18__BP _96/144 pox

Time15:42T 99.4_P __81_R _18__BP _97/150_pox 98

0800get reportmeet patientvital signs

0900medscheck on patient

1000breakfast/full liquidassist to bedside commodephysical assessment Respiratory: Liters O2 _2_____ Method __NC________

Treatments: O2 therapy 2L nasal cannula1100check on patient

Invasive lines: (list IV type and site, fluids and rate)

Site:__IV Peripheral Fluids: __KPO___Rate 125cc/hr____

Site:__________ Fluids: __________________Rate____

Site:__________ Fluids: ___________________Rate____

Bag Change Due: ______ Tubing Change Due: ________

1200-vital signs12:30 lunch mereturn to patient room/lunchassist to bedside commodebed bath Other tubes, drains, etc.

none1300change linens

Dressings: none

1400check on patientpost conference 1430

Diet: (list any difficulties) Full liquid diet, not tolerating

Day 1:Intake Output

Day 2:Input 820 Output 2

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Physical Assessment SheetFirst Page

Code Status __Full________

Allergies: ____NKA_________

Spiritual ____not listed___ Communication/Neuro Senses

Emotional/Mental Visual/Auditory

Circulation Status Respiratory Status

Skin Condition Wounds/Incisions/Decubitus

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A&Ox3 able to follow verbal commands. Glascow score 15. 100%ROM all extremities. Initiates communication speech clear.

Can hear normal tones, passes finger rub test. Wears glasses for both near and far vision. Able to read close and far away with assistance of glassss. PERRLA pupil size 2mm dim room light.

Patient pleasant, in pain but not depressed. States “I am tired of being here and I am ready to go home”

Apical HR 86, S1S2 normal rate, regular rhythm. PMI palpated between 4th and 5th intercostals space. B/P 148/88 left arm lying. Bilateral Peripheral pulses: carotid +3, Radial +3 normal rate/rhythm, brachial +3 Femoral +2,popliteal +2, dorsalis pedis +1. capillary refill fingernail1 sec, toenail 1 secNailbeds pink. Skin tone appropriate for race.

All breath sounds clear. No cough present, pulse ox 100% 2L O2 nasal cannula.

Temp 98.2 oral, Skin color pink, warm to touch, dry. Skin turgor 1 sec, redness/broken area beneath both breasts. Bilateral leg edema non pitting.

Broken skin under each breast, red, irritated. No incisions, no decubitus ulcers, patient has hemorrhoids. Left lower Abdominal scars 2 previous cesarean sections.

Physical Assessment SheetSecond Page

IV Site Mobility Status

Pain Assessment Nutritional Status(Use pain scale)

Elimination:

Bowels: Continent of bowel. Bowl sounds present x 4. Abdomen soft, non-distended. Pain with palpation upper right and left quadrants. Last BM 9/29/10 am loose, bloody stool.

Bladder: Patient semi continent of bladder, wears adult briefs. Urine clear yellow, no odor, no blood.

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Right peripheral IV #22. no sign of redness or swelling, no bleeding. IV intact/patent.

Patient ambulates with assistance. Can turn self in bed. Unsteady gait due to overall weakness. Stooping due to abdominal pain.

Patient states pain upper abdominal area. Pain level of 8 on 1-10 scale. Patient states that pain medicine does not make it better. Patient states that not moving and not applying pressure to the site helps. Turning/walking make worse.

Patient on full liquid diet. Unable to keep down food. Suffering from nausea and diarrhea. Patient on IV electrolyte protocol. Receiving KPO 125 cc/hr and magnesium replacement.

Physical Assessment SheetThird Page

ERIKSON’S DEVELOPMENTAL STAGE:Identify stage. Give rationale.

__ This patient has achieved the generativity stage of Eriksons Developmental stages.. She appears to be coping with her illness. Patient does not display any signs of self-absorption. She does not appear to be in denial or unhappy with advancing in age. She does not appear to be preoccupied with herself. She displays physical, emotional and social stability as was displayed with her relationship with visiting friends who state that she is generally happy and fun to be around. She does not appear withdrawn. Patient is tolerant and although she complains of pain, her mental status appears to be within reason for a person who has been hospitalized with an acute illness.Patient is capable of love, she has two children and a grand child of which she speaks highly of. Critical Thinking Questions

1. In relation to the primary disease process/es that the patient has, compare and contrast the actual signs and symptoms displayed by the patient to those listed in the textbook/reference that you used.

The primary health care problem that this patient has is Ischemic Cholitis and the patient displays textbook symptoms for the illness including, nausea, vomiting, bloody diarrhea, and pain in the lower left abdominial region.

2. Discuss how your patient’s history relates to the present condition or illness. If there is no relation please state so and explain.

The patients history does not relate to the present condition, as it is a condition that has an acute onset and is common in the elderly population. Bowel ischemia is mainly a disease of old age caused by atheroma of mesenteric vessels. Other causes include embolic disease, vasculitis, fibromuscular hyperplasia, aortic aneurysm, blunt abdominal trauma, disseminated intravascular coagulation, irradiation, and hypovolemic or endotoxic shock. This patient is neither symptomatic of nor displaying any signs of the above listed conditions. She is 71 years of age and it is most likely that her condition is related to age and atheroma of mesenteric vessels.

1. How did determine which health problem was priority? Discuss the rationale for your choice.

I chose Ischemic Cholitis as the primary problem because of the severity of her symptoms. The patient was admitted severely dehydrated and required electrolyte replacement therapy.The patient is not responding well to treatment even on a full liquid diet with bowel rest. She has been hospitalized for more than a week and is showing no improvement. A bowel resection may be necessary. Ischemic colitis is associated with chronic renal failure and atherosclerosis. If Ischemic Cholitis is not promptly under control, additional problems can occur, including death.

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CLINICAL LAB WORKSHEET

CHEMISTRY NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES

Sodium 136-145 143

Potassium 3.4-5.1 3.5

Chloride 99-110 109

CO2 23-32 20 Decreased CO2 levels can be attributed to increased ventilation. With increased ventilation, CO2 levels decrease. This can be because of pain or anxiety

Glucose 70-99 89

Bun 6-20 6

Creatinine 0.6-1.1 0.8

Uric Acid N/a

Calcium 8.5-10.5 7.9 Decreased calcium levels can mean hypoparathyroidism or renal failure

Phosphorous N/a

Total Protein N/a

Albumin N/a

Total Bilirubin N/a

Bilirubin, Direct N/a

Alk. Phosphatase N/a

SGOT/AST N/a

SGPT/ALT N/a

GGTP N/a

LDH N/a

Cholesterol N/a

LDL N/a

HDL N/a

VLDL N/a

Triglycerides N/a

Bun/CR Ratio 7.5 In prerenal injury, urea increases disproportionately to creatinine due to enhanced proximal tubular

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reabsorption. BUN level increases in upper GI bleeding because patients become prerenal, secondary to blood loss which decreases blood flow to the kidney

Bilirubin, Indirect N/a

Globulin N/a

A/G Ratio N/a

HEMATOLOGY NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES

WBC Count 3.7-9.1 7.6

RBC Count 3.8-5.3 3.62

Hemoglobin 11.1-15.8 9.7 Decreased levels of hemoglobin can indicate anemia, cirrhosis, hemolytic anemia, hemorrhage, dietary deficiency, renal disease

Hematocrit 32.5-48 29.2 Decreased hematocrit can indicate anemia, hemorrhage, dietary deficiency, bone marrow failure and renal disease.

MCV 80-101 80.6

MCH 27-32 26.7 Decreased MCV values mean the RBC is abnormally small or microcytic. This is associated with iron deficiency anemia or thalassemia.

MCHC 32-36.5 33.1 MCHC is a measure of the average concentration or percentage of hemoglobin within a single RBC. Decreased values mean that the cell has a deficiency of hemoglobin and is said to be hypochromic.

Red Cell Distr Width 11.5-14.5 14.3

Platelet Count 150-450 310

DIFF NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES

Polynuc Neutrophil 40-70 56

Band Neutrophil N/a

Lymphocyte 15-45 11 Decreased Lymphocytes can be indicative of leukemia, sepsis immunodeficiency diseases, lupus, erythematousus, later stages of HIV, aplastic anemia drug therapy and Lupus.

Monocyte 0-10 10

Eosinophils 0-6 5

Basophils 0-2 1

RBC Morphology N/a

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WBC Morphology N/a

Platelet Comments N/a

URINALYSIS NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES

Urine Specific Gravity N/a

Urine PH N/a

Urine Glucose N/a

Urine Bilirubin N/a

Urine Occult Blood N/a

Urine Urobilinogen N/a

Urine Nitrate N/a

Protein (Urine) N/a

Ketones N/a

Leukocyte. Ester. N/a

URINE MICRO EXAM NORMALS PT. VALUES EXPLANATION OF ABNORMAL VALUES

Urine WBC N/a

Urine RBC N/a

Urine Epithelial N/a

Urine Bacteria N/a

Urine Cast N/a

Urine Crystals N/a

Urine Misc. N/a

The following lab tests were not orderd

COAGULATION

PT __________________________ 11.0-13.0 SEC ________________________PTT __________________________ 22.0-32.0 SEC ________________________

ABG’sPH __________________________ 7.35-7.45 ________________________

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pCO2 __________________________ 35-45 ________________________po2 __________________________ 80-100 mmHg ________________________BASE _________________________ + OR – 3 mEq/L________________________HCO3 __________________________ 22-26 mEq/L ________________________O2 SAT.__________________________ 95-100% ________________________

OTHER

DIGOXIN _________________________ 1.0-2.0 ________________________DILANTIN _________________________ 10-20 ________________________THEOPHYLLIN _________________________ 10-20 ________________________

Other Diagnostic Test:

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MEDICATION PATIENTDOSERSD

ROUTE TIMES CLASSIFICATION MECHANISMOF ACTION

PATIENTSPECIFIC

RATIONALE

NURSINGIMPLICATIONS

electrolytereplacement

therapy

Adjusted according to need.

IV PRN .

amlodipine

5 mg daily po 0900 Vasodilators, hypotensive medicines

dihydropyridine calcium ion channel blocke

hypertension Check B/P and apical heart rate before administering

dorzolamide opthalmic

2 drops each eye 2xd

Opthalmolicdrops

0900 Ophthalmic glaucoma agents.

solution is comprised of two components: Dorzolamide Hydrochloride and Timolol Maleate. Each of these two components decreases elevated intraocular pressure

Treat glaucoma

esomeprazole40 mg daily IV injection 0900 ntisecretory

compoundsis a proton pump inhibitor that suppresses gastric acid secretion 

Treat reflux Monitor for headache, drowsiness, dry mouth, naseau

1 application topical 0900 topical steroids exact mechanism Hemorrhoids Avoid prolonged use,

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hydrocortisonetopical

2xd 2100 of action is not known

especially near eyes, in genital and rectal areas, on face, and in skin creases

MEDICATION PATIENTDOSERSD

ROUTE TIMES CLASSIFICATION MECHANISMOF ACTION

PATIENTSPECIFIC

RATIONALE

NURSINGIMPLICATIONS

metroidazoleflagyl

500 mg IV Injection

Q8hr Anti-infectives, antiprotozoals, antiulcer agents

Unionized metronidazole is selective for anaerobic bacteria due to their ability to intracellularly reduce metronidazole to its active form. This reduced metronidazole then disrupts DNA's helical structure, inhibiting bacterial nucleic acid synthesis and resulting in bacterial cell death.

Pevention of infection related to ischemic collits.

doses may need to be reduced in patients with liver disease and abnormal liver function

acetaminophen65 mg PO PRN nalgesic and

antipyretic On selective inhibitors of the enzyme cyclooxygenase (COX), inhibiting both the cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) isoenzymes. COX catalyzes the formation of prostaglandins and thromboxanefrom arachidonic acid 

Fever reducer

3 mg IV Injection

Q2hrPRN

opiate The presynaptic action of opioids to inhibit neurotransmitter release is

Pain management

Monitor vital signs, do not give if respirations are

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morphine considered to be their major effect in the nervous system

less than 10.

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1. Health problem & data 2. Health problem & data

Medical/surgical problem & priority assessment data

3. Health problem & data

Pain: assess pain characteristics Quality: Achy, sharp, throbbing. Severity (scale of 1 to 10) 8 Location (upper left and right abdominal quads)Onset (sudden) Duration (continuous)Precipitating or relieving factors: moving, walking touching/ reliving factors, lying still. Observe or monitor signs and symptoms associated with pain, BP 148/88, heart rate 86, temperature 98.2, color and moisture of skin pink, dry, restlessness but able to focus.

Impaired Mobility: Reluctance to attempt movement Limited range of motion (ROM)Decreased strength Imposed restrictions of movement including impaired coordination. Inability to perform action as instructed. Assess for impediments to mobility Identifying the specific cause (abdominal pain) Assess patients ability to perform ADLs effectively and safely on a daily basis. suggested Code for Functional Level Classification. 4 Is dependent, does not participate in activity Restricted movement affects the ability to perform most ADLs. Safety with ambulation is an important concern.

Ischemic Cholitis: nausea, vomiting, blood in stool, pain lower left abdominal region. Pain of 8 on scale of 1/10 onset sudden, duration, continuous. Patient unable to consume food/ on full liquid diet-intolerable. Bowl signs present x4. abdomen soft/ not distended, pain upon palpation/ movement. No lacerations/moles/lesions. Scarring from 2 previous cesarean sections.

Deficient Fluid Volume: inadequate fluid intake Active fluid loss (diuresis, abnormal drainage or bleeding, diarrhea) Failure of regulatory mechanisms Electrolyte and acid-base imbalances Increased metabolic rate (fever, infection) Fluid shifts (edema or effusions). Obtain patient history to ascertain the probable cause of the fluid disturbance (diarrhea). Monitor and document vital signs T 98.2 P 86 R 16 B/p 148/88 Assess skin turgor 1 sec and mucous membranes (pink/moist).

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HEALTH PROBLEM: ________Pain_____________________________________________________________________________________Behavioral Outcome (must be measurable and in a time frame):The patient will _verbalize adequate relief of pain or ability to cope with incompletely relieved pain by end of day of care on 9/29/10_____________ _________________________________________________________________________________

Nursing Interventions (action to meet outcome) Rationale Patient Response1.Anticipate need for pain relief. One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required

1. One can most effectively deal with pain by preventing it. Early intervention may decrease the total amount of analgesic required

1.Patient responded well to pain interventions such as assistance w/getting in and out of bed, bathing, and reaching.

2.Respond immediately to complaint of pain.

2. In the midst of painful experiences a patient’s perception of time may become distorted. Prompt responses to complaints may result in decreased anxiety in the patient. Demonstrated concern for patient’s welfare and comfort fosters the development of a trusting relationship.

2.Patients intolerace of pain was reported to the nurse and pain meds were given. After appropriate time, patient experienced less pain as stated “I feel a little better, but nothing helps much”.

3.Use relaxation exercises to bring about a state of physical and mental awareness and tranquility. Biofeedback, breathing exercises, music therapy

3.The goal of these techniques is to reduce tension, subsequently reducing pain.

3.patient responded well to back Massage Massaging decrease muscle tension and appeared to promoted comfort.

4.notify physician if interventions are unsuccessful or if current complaint is a significant change from patient’s past experience of pain.

4.Patients who request pain medications at more frequent intervals than prescribed may actually require higher doses or more potent analgesics.

4.After continuous interventions the patient still quoted a pain rating of 8 on a 1/10 scale. Nurse was notified.

May add more if appropriate on back of sheetSummarize overall progress toward outcome. Was the outcome met, partially met or unmet (explain)?__Outcome was patially met. Patient verbalized some relief with assistance with ADL’s and therapy such as back massage, but still continued to have a high rating and low tolerance for pain._________________________________

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HEALTH PROBLEM: _______Impaired mobility_____________________________________________________________Behavioral Outcome (must be measurable and in a time frame):The patient will __ perform physical activity independently or with assistive devices as needed by end of day of care on 09/29/10 .____________________________ __________________________________________________________________________

Nursing Interventions (action to meet outcome) Rationale Patient Response1.Assess for developing thrombophlebitis (e.g., calf pain, Homans’ sign, redness, localized swelling, and rise in temperature).

1. Bed rest or immobility promotes clot formation.

1.Patient did not complain of leg pain and bilateral legs did not show any signs of swelling or redness

2.Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation.

2. The longer the patient remains immobile the greater the level of debilitation that will occur.

2.Patient complained of pain with movement but was able to ambulate to and from the bedside commode with assistance.

3.Turn and position every 2 hours or as needed.

3. This optimizes circulation to all tissues and relieves pressure.

3.Patient was able to turn self and two hour turning schedule was adhered to.

4.Use prophylactic antipressure devices as appropriate.

4. This prevents tissue breakdown.

4.Patient was compliant with use of SED’s to promote circulation.

May add more if appropriate on back of sheetSummarize overall progress toward outcome. Was the outcome met, partially met or unmet (explain)? Overall progress toward outcome was fully met. Patient was compliant with use of SED’s, and was able to ambulate and perform ADL’s with assistance. _________________________

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HEALTH PROBLEM: _____Deficient Fluid Volume_________________________________________________________________Behavioral Outcome (must be measurable and in a time frame):The patient will _ experience adequate fluid volume and electrolyte balance as evidenced by urine output greater than 30 ml/hr, normal blood pressure, heart rate 100 beats/min, and normal skin turgor____________________________________________________________

Nursing Interventions (action to meet outcome) Rationale Patient Response1.Assess skin turgor and mucous membranes for signs of dehydration. 

1.The skin in elderly patients loses its elasticity; therefore skin turgor should be assessed over the sternum or on the inner thighs.

1.mucous membranes remained pink and moist throughout the day.

2.Encourage patient to drink prescribed fluid amounts. If oral fluids are tolerated, provide oral fluids patient prefers. Place at bedside within easy reach. Provide fresh water and a straw. Be creative in selecting fluid sources (e.g., flavored gelatin, frozen juice bars, sports drink).

2.Oral fluid replacement is indicated for mild fluid deficit. Elderly patients have a decreased sense of thirst and may need ongoing reminders to drink.

2.Patient was encouraged to drink liquids but this was difficult as she was nauseated. She was able to tolerate 460ml of tea and a few bites of green jello before the day’s end.

3.Provide oral hygiene.

3.This promotes interest in drinking.

3.Oral hygiene was provided but effectiveness could not be determined as the PIC line team came in right after her bath/oral hygiene.

4.Teach interventions to prevent future episodes of inadequate intake.

4. Patients need to understand the importance of drinking extra fluid during bouts of diarrhea, fever, and other conditions causing fluid deficits.

4.Patient was informed of interventions for preventing dehydrations.

May add more if appropriate on back of sheet. Summarize overall progress toward outcome. Was the outcome met, partially met or unmet (explain)? __Overall progress toward outcome was partially met. Patient did void twice during time of care and drank at least 400 ml of decaffeinated tea, however, adequate intake of fluids were not met. Blood pressure remained elevated throughout the day pulse remained WNL as did skin turgor._________________________________

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_____________________________________________________________________________________________________________________

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Patient Information:

Age _________71____Allergies ________nka__________

Code Status _____full_____ Physical Handicaps none______________

Primary Language ___English_________ Fall Precautions __y______ Isolation precautions n________________Medical Diagnosis/Illnesses:Ischemic Cholitis, Acute Renal Failure

Event of current illness:Patient admitted to hospital with chronic diarrhea and vomiting, unable to keep down food or liquids, pain in left lower abdominal region, malaise last several days

Pertinent past medical history:Chronic hypertension, chronic leg pain, malaise, last several days, left colon inflamed, UTI, Leukocytosis, abdominal pain, glaucoma

Results of X-rays, labs, cultures, or scans related to disease process:

Anticipated tests, labs, surgeries, procedures, appointments for clinical day:

PICC line insertion

Priority Health Problem & Nursing Assessments: (s/s indicate pt is experiencing complications)Ischemic Cholitis: nausea, vomiting, blood in stool, pain lower left abdominal region. Pain of 8 on scale of 1/10 onset sudden, duration, continuous. Patient unable to consume food or liquids.

Notes:

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